CASE

“Do you want to see me again?”

As a resident a very attractive woman came to see me with pityriasis rosea on her breasts. I examined her, made the diagnosis and told her that although it would take some time, her condition was benign and would heal spontaneously. I told her to come back in a couple of weeks and we'd see if her skin had cleared up. She came back and indeed I was able to tell her “That's fine, it's completely gone.” Later, to my astonishment she made another appointment to come and see me. When I entered the room she had already removed her clothing and wanted me to check her. There was no indication she needed medical attention, and I began to suspect that something less professional was going on. She said, “Well, do you want to see me again?”

CASE

“I don't think I took advantage of her”

One night when I was a resident a female patient asked me to undress her. I did and, at her urging, got into bed with her and had sex. After that I went to her room for sex several times while she was in the hospital. We saw each other for some time after her discharge. I've never told anyone about this. She initiated the sex and it was entirely consensual, I don't think I took advantage of her.

In this section we explore deprecating humor. People need a release valve in highly charged emotional situations and using humor is a common way to let off steam. However, danger exists when patients are demeaned in the process. All too often, this kind of humor is used to establish distance and hierarchy as well as a way to overcome fear and anxiety. How should such depersonalizing behavior be handled?

CASE

“Who am I”

As medical students we were not discouraged from introducing ourselves by saying “Hello, I'm Dr. So and so,” as opposed to identifying ourselves as students. If we happened to be doing rounds with an intern or resident, the physician would introduce himself or herself as “Dr. X and over here is Dr. Y” – indicating a student. When I introduced myself as a medical student, I got the feeling people thought it was silly or unnecessary.

CASE

“Don't tell her you are a medical student”

As a medical student I overheard an intern tell a fellow third year student to get a history from a patient, “But, don't tell her you are a medical student because she won't talk to you.”

CASE

“Premature description”

As medical students we were given no instructions as to the proper way to identify ourselves to patients. I saw classmates introducing themselves as “Dr.” and one student even secured a credit card with “MD” after his name. I was uneasy about this less than honest self-description, but the practice was common and the perpetrators were never corrected by faculty.

CASE

“If you weren't so fat”

After undergoing a Cesarean section, a very fat woman developed a wound infection that was not healing. The chief resident, who had also performed the surgery, became very frustrated over the fact that this untoward event had occurred on his watch. He rebuked the patient in front of a room full of students and house staff by telling her, “If you weren't so fat this simply wouldn't be a problem.”

The patient happened to be Tongan and, consequently, she did not understand most of what the chief resident was saying. He continued to rail away at her in front of the assembled group, punctuated by an occasional, “You understand what I'm talking about don't you!” The patient would simply smile and nod, clearly uncomprehending.

I believed the patient was being used for the chief resident to absolve himself of any responsibility for the infection. As on-lookers, and underlings, what should we have done?

CASE

“The patient removed the traction”

When my friend and I were students on the ward, he was assigned the responsibility of arranging for traction to be set up for a patient. From subsequent events, I believe that he mistakenly ordered the wrong traction and then blamed the patient.

Perhaps the most looming obstacle for trainees trying to act morally is the perception of medical hierarchy and struggling to find their place in that hierarchy. Challenging the decisions and actions of someone higher in authority can be the most threatening and unsettling of dilemmas. Inevitably moments arise when trainees question the decisions of their superiors. This raises tremendous conflicts. Should they press to question authority, or stifle their objections in respectful silence? To what extent should they perhaps put their career in jeopardy by challenging the system? What should the response be, for example, if the student is asked to do a procedure a superior does not want to do, on for example an AIDS patient? At the same time, positioning oneself for a more favorable place in the hierarchy, even to the detriment of peers, becomes difficult to resist. This problem of accepting the status quo is amplified when influence is peddled by drug companies and other outside forces.

One physician-educator we interviewed for the book concluded,

Currently ward ethics issues are handled, when they are handled at all, on an ad hoc basis. The message is that these issues are not that important. The situation must change but it will not change overnight and it will not change without ruffling feathers.

Even if some feather-ruffling is inevitable, given any institution's natural resistance to change, there are still a number of ways in which training dilemmas such as those described in this book could be identified and addressed. Our recommendations can be summarized in three categories: education, reporting, and organizational responsibility.

Education

Educational opportunities can range from occasions as informal as brown bag lunches to ward ethics cases incorporated as an integral part of the curriculum itself. The latter might take the form of:

1 Ward ethics rounds. Once a week the various services could devote one of their rounds to ward ethics dilemmas. During these sessions trainees present cases and participate in a forum on how best to address the issues generated on this particular service. For example, the intern who complained of her discomfort in being given an order to deliver devastating news to a patient with whom she had had no previous contact, would have the opportunity to discuss her own feelings and response.

CASE

“The patient had been verbally assaulted”

On my medical rotation there was a Black patient who was an IV drug user. The resident was exasperated about her failure to comply and lashed out at the woman by saying that her 13-year-old daughter should be searched when she came to see her mother because she was probably bringing in drugs. I was horrified and felt that the patient had been verbally assaulted, but I didn't know what to do about it.

CASE

“Stop bothering us”

As a student I was asked to work up an elderly man with all sorts of pains, including back pain. He had severe arthritis and had been in and out of the hospital many times. He was obviously somewhat depressed and feeling his pain terribly. As we spoke, he almost warned me, “No one believes me, I am in terrible pain.” I had just opened the door to his room to present as the resident came by, when the resident shouted out in a very loud offensive way, as though deliberately trying to make sure the patient heard, “Well, tell me, is this patient's pain legitimate or not?” I felt miserable because I knew the patient's pain from his own perspective was “legitimate.” But, of course, there was nothing the orthopedic surgeon was going to be able to do and therefore as far as he was concerned it wasn't “legitimate.”

To acknowledge?

CASE

“The camouflaged patient”

I was on a surgical rotation and the patient was an elderly woman who had developed a severe postoperative infection after undergoing a cholecystostomy. The surgical residents were terrorized as to what the attending physicians would say on rounds. In an attempt to camouflage the patient's condition, the residents staged a scene in which they propped her up with pillows and put a breakfast tray in front of her to make her look better than she really was.

CASE

“Didn't you write that order?”

A very sick patient on the cardiac care unit was waiting for a heart transplant. Hospital routine was such that, beginning on Thursday, residents or interns on call left the care of their patients to others over the weekend, often during critical periods of hospitalization. As an intern, it fell to me to cover this particular cardiac patient for another intern on his weekend off.

Before he signed out, the intern stated his concern that despite high doses of potassium the patient's level remained low. Because there was no apparent renal insufficiency, I decided to increase the potassium dose and scheduled a dose of 3 times a day, assuming it would be monitored in my absence. The next morning the level was normal, so I continued him on that dose.

Recently, I received the following letter from a young woman:

I am a lowly intern and I've had a long hard extraordinary week, some of it exhilarating. I haven't really slept in weeks and when I do sleep, I dream of my patients. I sent a little old lady with dead legs home to die. I told a man today he had cancer. It's late at night now, and I am worrying about them, but also I'm worrying about me. I'm so tired and lonely and I'm starting to laugh (hard) at things I shouldn't laugh at. I don't understand exactly what is happening to me – but it's happening fast …

Here is a person, like many of you, in dire need. She wants to be a doctor – and a good one – but her training experiences are making her question her ability, her knowledge, and why she went into this profession in the first place.

The answer to why we choose medicine is very individual. In my own case, medicine was a part of my heritage. My father was a general practitioner and from my earliest days, when we lived upstairs and he worked downstairs, I heard the cries and moans of the patients he was treating and hurting. When he died, I was only 12; I decided I would be his reincarnation. It seemed the noblest thing in the world to do – a person who could heal wounds could do anything, and I still believe it.

Truth-telling is a major feature of physician– patient interactions. On the one hand, professionals must tell the truth so that patients can adequately make decisions about their health care. On the other, patients must have sufficient trust in the relationship to give accurate and forthright responses to their doctors. In this section some of the complexities of truth-telling are raised. Questions about the appropriateness of disclosing information only arise when there is some sort of psychological resistance to disclosing a particular kind of information. What are the limits of disclosure? Is misleading through dissembling and obfuscation justifiable?

CASE

“I fled from the room”

As a female medical student I was conducting my first physical exam on a male patient, in the presence of classmates and supervising faculty, when it became quite apparent to all that the patient had an erection. I was taken by surprise, flustered and embarrassed, and not knowing how to deal with the situation, I fled from the room. Later, my male colleagues couldn't understand my response. I know my unprofessional behavior added to the discomfort of the patient, a young man not very much older than myself. For that I am profoundly sorry. I was not prepared for such a situation and still have received no instruction as to how best to manage a similar future occurrence – for the patient's sake as well as my own.

CASE

“I still don't know what I did wrong”

I was a third year medical student when one of our patients needed to have a nasogastric tube put in. The team turned to me and told me to see to it that this was done – and then they all disappeared. Before, in similar situations, a resident would say “Let's get the stuff and do it” but this time I found myself entirely alone. A day or two earlier, a resident had showed me the procedure; so, I went to find him. However, this time he just said “I've already shown you how to do that, just get it down. Call me if you have any problems.”

Questioning authority

CASE

“Just a consult”

The other day I saw a patient being treated for hyponatremia with salt tablets. Between the morning and afternoon rounds, he went from being arousable to barely responsive to pain. I talked to my attending about my observations but he was uninterested since, as he indicated, we were not the medicine team, but just a consult. We did not notify any of the doctors about the patient's decreased level of consciousness. The next day he was in the ICU on a ventilator.

CASE

“Don't mess with the chain of command”

During rounds with the chief resident and the attending, the attending laid out a course of treatment for the patient. Rather than question the attending's judgment, out of her earshot the chief resident said “No one does it that way, but we're just going to let this go and it's going to bite her in the ass.” There seemed to be no concern for the impact on the patient, and I asked, “Can't we talk to another attending?” The chief resident responded with an emphatic, “No way! There is a strict hierarchy here. You only go through your attending and if you mess with that chain of command by going around her, you'll get it!” I was left with the question, “Where does the patient figure in this chain of command?”

CASE

“You idiot! What are you doing in medical school?”

Five of us were working together dissecting a cadaver in anatomy lab. It was day three of the course and there were two hours left to complete the day's assignment. The student who self-appointed herself as the group leader was assertive and eager to dissect but had botched up one dissection already, making it difficult to identify certain parts of the anatomy. Another student decided to confront her and said, “You idiot! You've completely destroyed this cadaver! What are you doing in medical school?”

I was very worried about not getting the assignments done on time and debated with myself about involving the preceptor, but I didn't know how to proceed.

CASE

“I would knock you to the floor”

I was a third year medical student on a largely surgical obstetrics and gynecology rotation. We rounded on patients at 7: 00 a.m. and I was responsible for one of the four patients on the postsurgical floor. My responsibility required getting up early, checking out her vital signs, talking to her about what was going on with her, asking about any pain she might be experiencing, going over her medications and her history. I had to make sure I knew everything.

CASE

“Patients I don't like”

Patients I don't like fall into two categories: those who are rude, offensive and I wouldn't like them under any circumstances, and those who behave in a way that makes it difficult for me to do my job – they are noncompliant, don't tell me when they are taking alternative therapies that may have a bearing on the treatment program, etc. I find that I give these patients less energy, less time and their care necessarily suffers. When I expressed these feelings to my chief he came down very hard on me and said that physicians owe all patients equally, but I find it is only human nature to make distinctions.

CASE

“Why should I invest in these patients?”

I have very strong feelings about patients who engage in self-destructive behaviors, e.g., obesity, smoking, drug abuse, etc. I tell them the risk factors; but for the most part they won't change their behavior. They respond with giggles or a look that says, “So what?” I keep my involvement with these patients to a minimum. I don't need to bang my head against a wall since they're not banging their heads. Just because I'm a resident why should I invest more in these patients than they are willing to invest in themselves?

CASE

“Patient or cadaver?”

One evening during my first year of medical school I was observing a preceptor in the Emergency Department. A paramedic-staffed ambulance brought in a man who had been in cardiac arrest for some time. In the Emergency Department it was clear from the start that the situation looked very grim. The doctor asked if I was CPR certified and if I wanted to do cardiopulmonary resuscitation on this patient. I told him that I was certified, but I wasn't ready to take on this situation. He brushed aside my reluctance and said, “Don't worry about it. Go ahead and try. I'll be here next to you.” I administered effective CPR. Yet nothing worked, and eventually the patient was declared dead.

At that point, the curtain was pulled around the bed and the doctor told me he was going to practice intubation using the corpse that, only moments ago, had been his patient. He explained that since all the paramedics were now trained to intubate patients in the field, he seldom had the opportunity to practice this important skill. Since he didn't want to lose his proficiency, he felt this was a good way to maintain it. Later, I heard that there was also a group of training paramedic students who needed intubation experience and were invited to make use of this “practice opportunity.”

All relationships within a hospital are based on the authority of one person over another. When medical students first arrive on a hospital ward, they immediately find themselves enmeshed in a pre-existing, well-defined system of hierarchical work relations. Taking their place alongside (or more likely in back of) staff physicians, residents and interns, students join the medical sector of the ward community, which – apart from patients – otherwise consists almost exclusively of people whose work supports the doctors in their therapeutic activities.

Part of the task for any newcomer seeking entry to an established group is to identify, and be identified with, the prevailing culture. Medical education, like other professional socialization experiences, seeks to assimilate individuals into the system by imbuing them with a sense of group solidarity, obeisance, and esprit de corps. The wards in which doctors in training gradually learn to be part of the medical team provide the most powerful structure for this aspect of the socialization process.

Idealistically, and perhaps naively, it is often assumed that, in addition to the acquisition of knowledge and skills, during their apprenticeship on the wards, medical trainees will be exposed to the attitudes and values of senior physicians who, through instruction and example, will nurture those attributes society expects from the medical profession, e.g., compassion, integrity, and a sense of professional ethics. Although this idealistic portrayal of life on the wards sometimes does occur, the history of the emergence of the teaching hospital attests to the hurdles to be overcome and idealism's subsequent rarity.

When does a doctor become a doctor? We queried doctors from a wide range of specialties, age groups, and geographical locations and asked them to describe what marks the transition: What event or events must transpire in order to turn a “civilian” into a professional? Initially, they recited moments that signified “offcial” recognition, such as: “When I received the white coat” or “At my graduation” or “When I received my license.” However, the real significance of such external signposts is captured in one doctor's story of the day he realized “the power of the white coat:”

I started the “Physical Diagnosis” class at my medical school just as I had completed most of my basic sciences courses. The class was taught by the chief of medicine, one of the best clinicians I've ever known. The first day set the format for the course.

CASE

“How ‘confidential’ is confidential?”

The patient was a 13-year-old African–American male who presented to the pediatric clinic with his acting guardian from the boys' home for an entry physical examination. The clinic is staffed by a group of physicians who rotate through on different days of the week, as do the residents and medical students like myself. Providers at the clinic see children from underserved populations and frequently have patients from the local boys' home for physical exams and minor treatment. This young man was like most other children his age, basically healthy and active. He had been sent to the boys' home after driving a stolen car under the influence of alcohol, in addition to a previous history of other legal infractions.

His only health complaint was that he suffered from significant allergies that were causing him congestion and discomfort. He worried this problem might affect his trying out for the freshman football team. As the resident proceeded with the history, I examined the patient and listened. He appeared to be having trouble understanding the resident's accent and clearly did not appreciate how she was phrasing some of the questions, particularly the one implying drug use.

When she left, I remained with the patient, who had denied any drug use. We had a relaxed conversation about the importance of confidentiality in the doctor–patient relationship and how greater accuracy of the history will lead to greater efficacy of treatment.